Basic Information
| Provider Information | |||||||||
| NPI: | 1871726679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LEON | ||||||||
| FirstName: | IVY | ||||||||
| MiddleName: | GERALYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 BILLINSGATE CT | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281176702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048801466 | ||||||||
| FaxNumber: | 7048801466 | ||||||||
| Practice Location | |||||||||
| Address1: | 557 BROOKDALE DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286774100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048735661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 182897 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2594567D | 01 | NC | MEDICARE PTAN, INDIVIDUAL | OTHER | 7000658 | 05 | NC | MEDICAID |